Non-alcoholic Fatty Liver Disease

in Children

• Dr CSN Vittal
 Non-Alcoholic Fatty Liver Disease (NAFLD)
• Non-alcoholic fatty liver disease (NAFLD) is the build up of extra fat in
liver cells that is not caused by alcohol.
• If more than 5% – 10% percent of the liver’s weight is fat, then it is
called a fatty liver (steatosis).

• American liver foundation

 Non-Alcoholic Fatty Liver Disease (NAFLD)
• Most prevalent form of chronic liver disease, affecting 10%–20% of the general paediatric
population.
• Within the next 10 years it is expected to become the leading cause of liver pathology, liver failure
and indication for liver transplantation in childhood and adolescence in the Western world.
• 90% of those undergoing bariatric surgery have NAFLD
• Prevalence of childhood NAFLD globally is in the range of 9 to 37%
• Prevalence of NAFLD in normal-weight children and overweight/obese children is reported to range
about 3-10% and 8-80%, respectively
• Prevalence of fatty liver in the general adult population of India is in the range of 5% to 28%, with
higher prevalence among the overweight and diabetics
• Prevalence of NAFLD in normal-weight children and overweight/obese children is reported to range
about 3-10% and 8-80%, respectively
 Non-Alcoholic Fatty Liver Disease - Stages
1. Simple fatty liver (steatosis) – a largely harmless build-up of fat in the liver cells that
may only be diagnosed during tests carried out for another reason
2. Non-alcoholic steatohepatitis (NASH) – a more serious form of NAFLD, where the
liver has become inflamed; (this is estimated to affect up to 5% of the UK population)
3. Fibrosis – persistent inflammation causes scar tissue around the liver and
nearby blood vessels, but the liver is still able to function normally
4. Cirrhosis – the most severe stage, occurring after years of inflammation, where the
liver shrinks and becomes scarred and lumpy; this damage is permanent and can lead
to liver failure and liver cancer

• https://www.nhs.uk/conditions/non-alcoholic-fatty-liver-disease/
 NASH
• Hepatic steatosis
• Active hepatocyte
inflammation in the form
of ballooning
degeneration
• Risk of fibrosis and
progression to
Ballooning degeneration:
--Form of cell death (apoptosis).
cirrhosisHCC
--Name derived from the fact that the cells undergoing this • Requires a liver biopsy for
form of cell death increase in size or “balloon”
--Descriptive term used in the context of steatohepatitis
diagnosis
Mallory bodies are damaged intermediate filaments within
the hepatocytes.
 What populations are at higher
risk for NAFLD?

• Major components of the

metabolic syndrome.
• The presence of at least three of
these components define the
presence of metabolic syndrome.

• Drug Metab Rev. 2017 May; 49(2): 197–211.

 What populations are at higher
risk for NAFLD?
• Risk Factors
• Obesity, (↑ risk with advancing BMI and waist circumference)
• Impaired fasting glucose
• Hispanic heritage
• Male gender
• Advancing age
• Coined the “Hepatic Manifestation” of Metabolic syndrome
• Those with the PNPLA3 genotype MM have an increased
tendency for hepatic fat storage
 Clinical Presentation
• The mean age of diagnosis is 11–13 years old
• A dull or aching pain in the top right hypochondrium
• extreme tiredness
• unexplained weight loss
• Weakness
• liver might be slightly enlarged and
• acanthosis nigricans - commonly over the neck and the under arm area.
• If cirrhosis develops,
• jaundice
• itchy skin, and
• oedema
• NAFLD-associated comorbidities, including insulin resistance and Type II
Diabetes Mellitus,
 Clinical Indicators

• The presence of any of the following, especially with a history of

abnormal AST/ALT, should lead to a work
— Presence of obesity, especially morbid obesity (BMI > 35)
— Diagnosis of type 2 diabetes mellitus
— Diagnosis of metabolic syndrome
— History of obstructive sleep apnea
— Presence of insulin resistance
— Chronic elevation of AST/ALT, otherwise unexplained
 NAFLD - Pathogenesis

• A complex interaction among environmental factors (i.e., Western

diet), obesity, changes in microbiota, and predisposing genetic
variants resulting in a disturbed lipid homeostasis and an excessive
accumulation of triglycerides and other lipid species in
hepatocytes. Insulin resistance is a central mechanism that leads to
lipotoxicity, endoplasmic reticulum stress, disturbed autophagy,
and, ultimately, hepatocyte injury and death that triggers hepatic
inflammation, hepatic stellate cell activation, and progressive
fibrogenesis, thus driving disease progression.
 NAFLD - Pathogenesis

• Two hit Hypothesis : (now obsolete)

• Leptin may stimulate inflammation, fat storage
• Adiponectin is anti-inflammatory, anti-steatotic
• Multi hit Hypothesis
• Multiple insult acting together on genetically
predisposed subjects.
 “Two Hit” Hypothesis
• Sedentary lifestyle • Oxidative Stress
• High fat diet • Mitochondrial Dysfunction
• Insulin resistance • Inflammatory Cytokines
• Obesity • Gut Dysbiosis, Endotoxins
1 2

Normal Liver NAFL NASH Cirrhosis

“Simple Steatosis”
Clin Med (Lond). 2015 Apr
 “Multi-hit” Hypothesis

• Multiple insults acting together on genetically predisposed patient

(insulin resistance, altered gut bacteria, inflammatory cytokines..etc)

• Not necessarily a linear progression from simple steatosis to NASH

• Currently most accepted understanding of NAFLD

 “Multi-hit” Hypothesis

• Multiple insults acting together on genetically predisposed patient

(insulin resistance, altered gut bacteria, inflammatory cytokines..etc)

• Not necessarily a linear progression from simple steatosis to NASH

• Currently most accepted understanding of NAFLD

 “Multi-hit” Hypothesis

Interplay between Diet, Microbiota, and Host Genetics

1. Adipose tissue inflammation

2. De novo Lipogensis (DNL)
3. Insulin Resistance
4. Lipotoxicity
5. Mitochondrial Dysfuntion
6. Oxidative Stress
7. Endoplasmic Reticulum Stress
8. Microbiota Associated Mechanism
9. Short-Chain Fatty Acids (SCFAs) Relevant
Mechanism
10. Dietary Choline Mechanism
11. Bile Acid Pool Related Mechanism
12. Endogenous Alcohol Theory
13. Intestinal Permeability and Endotoxemia
14. Saturated Fatty Acids
15. Fructose
16. Genetics
17. PNPLA3 ( Patatin-Like Phosopholipase Domain
Containing 3)
18. TM6SF2 (Transmembrane 6 Superfamily Member 2)

• Gastroenterology Research and Practice Volume 2016, Article ID 2862173, 13 pages

 1. Adipose tissue inflammation

• Adipocytes under inflammation secrete cytokines and chemokines, particularly tumor

necrosis factor-α (TNF-α), interleukin-6 (IL-6), and CC-chemokine ligand-2 (CCL2)
• Adipose tissue-derived TNF-α and IL-6 have been shown to regulate hepatic insulin
resistance via upregulation of SOCS3, a suppressor of cytokine signalling
• CCL2 recruits macrophages to the adipose tissue, resulting in even more local cytokine
production and perpetuating the inflammatory cycle;
• TNF-α and IL-6 induce a state of insulin resistance in adipocytes, which stimulates
triglyceride lipolysis and fatty acid release into the circulation.
• extrahepatic adipocytes are compromised in their natural ability to secrete adiponectin, an
anti-inflammatory adipokine that facilitates the normal partitioning of lipid to adipocytes for
storage
• Together, these abnormalities accentuate fat loss from adipocytes and promote ectopic fat
accumulation.
• H. Tilg, “The role of cytokines in non-alcoholic fatty liver disease,” Digestive Diseases, vol. 28, no. 1, pp. 179–185, 2010.
• C. M. Hasenour, E. D. Berglund, and D. H. Wasserman, “Emerging role of AMP-activated protein kinase in endocrine control of metabolism in the liver,” Molecular and
Cellular Endocrinology, vol. 366, no. 2, pp. 152–162, 2013
 2. de novo Lipogensis (DNL)

• A 3-fold higher rate of de novo fatty acid synthesis is seen in these

subjects.
• fructose is a more potent inducer of DNL than glucose
• dietary fat, particularly saturated fat, stimulates DNL by upregulating
SREBP-1 (sterol responsive element binding protein), a key regulator
of the lipogenic genes in the liver

• J. E. Lambert, M. A. Ramos-Roman, J. D. Browning, and E. J. Parks, “Increased de novo lipogenesis is a distinct

characteristic of individuals with nonalcoholic fatty liver disease,” Gastroenterology, vol. 146, no. 3, pp. 726–735,
2014.
 3. Insulin Resistance

• Serine phosphorylation of insulin receptor substrates by inflammatory

signal transducers such as c-jun N-terminal protein kinase 1 (JNK1) or
inhibitor of nuclear factor-κB kinase-β(IKK-β) is considered one of the key
aspects that disrupts insulin signalling
• Insulin resistance is characterized not only by increased circulating insulin
levels but also by increased hepatic gluconeogenesis, impaired glucose
uptake by muscle, and increased release of free fatty acids and
inflammatory cytokines from peripheral adipose tissues, which are the key
factors promoting accumulation of liver fat and progression of hepatic
steatosis

• M. Gaggini, M. Morelli, E. Buzzigoli, R. A. DeFronzo, E. Bugianesi, and A. Gastaldelli, “Non-alcoholic fatty liver
disease (NAFLD) and its connection with insulin resistance, dyslipidemia, atherosclerosis and coronary heart
disease,” Nutrients, vol. 5, no. 5, pp. 1544–1560, 2013.
 4. Lipotoxicity

• Lipids, including Free cholesterol (FC), long chain saturated fatty acids (SFA), and
certain lipid intermediates from excessive SFA, can activate a variety of
intracellular responses such as JNK1 and a mitochondrial death pathway, resulting
in lipotoxic stress in the endoplasmic reticulum and mitochondria, respectively.
• The toll-like receptor 4 (TLR4) is a pattern recognition receptor that activates a
proinflammatory signalling pathway in response to excessive SFAs.
• This pathway is initiated by recruiting adaptor molecules such as toll/IL-1
receptor domain containing adaptor protein (TIRAP) and myeloid differentiation
factor 88 (MyD88) that ultimately lead to activation of nuclear factor κB with
production of TNF-α

• T. Sharifnia, J. Antoun, T. G. C. Verriere et al., “Hepatic TLR4 signaling in obese NAFLD,” American Journal of
Physiology—Gastrointestinal and Liver Physiology, vol. 309, no. 4, pp. G270–G278, 2015
 5. Mitochondrial Dysfunction

• Reduced enzymatic activities of mitochondrial electron transport

chain (ETC) complexes may be attributed to increased generation of
reactive oxygen species (ROS) as a result of ETC leakage during
mitochondrial β-oxidation in energy production (in the form of ATP)

• C. P. Day, “Pathogenesis of steatohepatitis,” Best Practice & Research Clinical Gastroenterology, vol. 16, no. 5,
pp. 663–678, 2002.
 6. Oxidative Stress

• Recent studies support the idea that oxidative stress may be a

primary cause of liver fat accumulation and subsequent liver injury
• ROS-induced expression of Fas-ligand on hepatocytes may induce
fratricidal cell death.
• These species can initiate lipid peroxidation by targeting
polyunsaturated fatty acids (PUFAs), resulting in the formation of
highly reactive aldehyde products, such as 4-hydroxy-2-nonenal (4-
HNE) and malondialdehyde (MDA)
• D. Pessayre, “Role of mitochondria in non-alcoholic fatty liver disease,” Journal of Gastroenterology and
Hepatology, vol. 22, supplement 1, pp. S20–S27, 2007
 7. Endoplasmic Reticulum (ER) Stress

• Under pathological and/or stressful conditions such as NASH, it has been observed that
ER efficiency in the protein-folding, repairing, and/or trafficking machinery is decreased
while the demand of protein synthesis and folding/repair is increased.
• This type of cellular stress usually triggers an adaptive response, aimed at resolving ER
stress, called unfolded protein response (UPR)
• The UPR is mediated by at least three different stress-sensing pathways:
- protein kinase RNA-like ER kinase (PERK),
- inositol-requiring protein 1α (IRE1α), and
- activating transcription factor 6 (ATF6)

• D. Ron and P. Walter, “Signal integration in the endoplasmic reticulum unfolded protein response,” Nature
Reviews Molecular Cell Biology, vol. 8, no. 7, pp. 519–529, 2007
 8. Microbiota Associated Mechanism

• Gut microbiota may contribute to the pathogenesis of NAFLD through

several mechanisms
1. Increased production and absorption of gut short-chain fatty acids;
2. Altered dietary choline metabolism by the microbiota;
3. Altered bile acid pools by the microbiota;
4. Increased delivery of microbiota-derived ethanol to liver;
5. Gut permeability alterations and release of endotoxin; and
6. Interaction between specific diet and microbiota.

• P. Lin, J. Lu, Y. Wang et al., “Naturally occurring stilbenoid TSG reverses non-alcoholic fatty liver diseases via gut-
liver axis,” PLoS ONE, vol. 10, no. 10, Article ID e0140346, 2015
 9. Short-Chain Fatty Acids (SCFAs)
Relevant Mechanisms

• As an energy precursor, SCFAs are implicated in the pathogenesis of NAFLD

because of their possible contribution to obesity. BUT ???
• Beneficial effects of SCFAs
• immunoregulation, enhanced intestinal barrier function,
• acting as a histone deacetylase 1 (HDAC) inhibitor to decrease expression of lipogenic
genes and to increase carnitine palmitoyltransferase 1A expression , and
• a peroxisome proliferator-activated receptor-γ- (PPARγ-) dependent mechanism,
shifting metabolism in adipose and liver tissue from lipogenesis to fatty acid oxidation

• P. Lin, J. Lu, Y. Wang et al., “Naturally occurring stilbenoid TSG reverses non-alcoholic fatty liver diseases via gut-
liver axis,” PLoS ONE, vol. 10, no. 10, Article ID e0140346, 2015
 10. Dietary Choline Mechanism

• Dietary choline-deficiency has been linked with a variety of conditions

including hepatic steatosis.
• Choline has role in fat export out of the hepatocytes
• Choline-depleted diet revealed that increased Gammaproteobacteria
abundance and decreased Erysipelotrichi abundance were protective
against developing steatosis

• M. D. Spencer, T. J. Hamp, R. W. Reid, L. M. Fischer, S. H. Zeisel, and A. A. Fodor, “Association between

composition of the human gastrointestinal microbiome and development of fatty liver with choline
deficiency,” Gastroenterology, vol. 140, no. 3, pp. 976–986, 2011
 11. Bile Acid Pool Related Mechanisms

• Bile acids have also been recognized as important

cell signaling molecules regulating lipid
metabolism, carbohydrate metabolism, and
inflammatory response

• R. H. McMahan, X. X. Wang, L. L. Cheng et al., “Bile acid receptor activation modulates hepatic monocyte
activity and improves nonalcoholic fatty liver disease,” The Journal of Biological Chemistry, vol. 288, no. 17, pp.
11761–11770, 2013
 12. Endogenous Alcohol Theory

• The composition of NASH microbiomes was found to be distinct from those

of healthy and obese microbiomes, and Escherichia stood out as the only
abundant genus that differed between NASH and obese patients.
Because Escherichia are ethanol producers, this finding is in agreement
with their previous report that alcohol-metabolizing enzymes are
upregulated in NASH livers
• Alcohol theory currently faces conflicting results from different
investigators.

• I. C. de Medeiros and J. G. de Lima, “Is nonalcoholic fatty liver disease an endogenous alcoholic fatty liver
disease?—a mechanistic hypothesis,” Medical Hypotheses, vol. 85, no. 2, pp. 148–152, 2015.
 13. Intestinal Permeability and
Endotoxemia

• Changes in the composition of microbiota can lead to increased intestinal

permeability and subsequent overflow of harmful bacterial by-products to
the liver that in turn triggers hepatic inflammation and metabolic
disorders.
• Endotoxin, that is, lipopolysaccharide (LPS), is derived from Gram-negative
bacteria, and it has long been implicated in chronic liver diseases
• LPS and other exogenous stimuli are responded to first by innate immunity
through pattern recognition receptors such as toll-like receptors (TLRs) and
NOD-like receptors (NLRs)

• R. Medzhitov, “Toll-like receptors and innate immunity,” Nature Reviews Immunology, vol. 1, no. 2, pp. 135–145,
2001.
 14. Saturated Fatty Acids

• In liver and hepatocytes not exposed to alcohol, SFAs appear to promote

apoptosis and liver injury
• SFAs increase the saturation of membrane phospholipids, thus initiating unfolded
protein response (UPR) and leading to ER stress
• SFAs also affect mitochondrial metabolism and promote ROS accumulation
• SFAs can interact with gut microbiota to affect the progression of liver injury
• Overflow of SFAs to the distal intestine reduced microbial diversity and increased
the Firmicutes-to-Bacteroidetes ratio in the intestine

• D. Wang, Y. Wei, and M. J. Pagliassotti, “Saturated fatty acids promote endoplasmic reticulum stress and liver
injury in rats with hepatic steatosis,” Endocrinology, vol. 147, no. 2, pp. 943–951, 2006.
 15. Fructose

• Excess fructose consumption is involved in the pathogenesis of NAFLD and

that upregulated de novo lipogenesis and inhibited fatty acid β-oxidation
are distinct metabolic processes for the development of hepatic steatosis in
individuals with NAFLD
• Increased fructose consumption is associated with a higher fibrosis stage in
patients with NAFLD, independent of age, sex, BMI, and total calorie intake
• Increased expression of TLRs has been implicated in the development of
fructose-induced hepatic steatosis

• M. F. Abdelmalek, A. Suzuki, C. Guy et al., “Increased fructose consumption is associated with fibrosis severity in
patients with nonalcoholic fatty liver disease,” Hepatology, vol. 51, no. 6, pp. 1961–1971, 2010.
 16. Genetic Background of NAFLD

• Genetic variation does influence disease risk in NAFLD

• Dozens of genes with multiple polymorphisms have been discovered in
genome-wide association studies (GWAS) that may be responsible for risk
of NAFLD in certain populations

• F. S. Macaluso, M. Maida, and S. Petta, “Genetic background in nonalcoholic fatty liver disease: a comprehensive
review,” World Journal of Gastroenterology, vol. 21, no. 39, pp. 11088–11111, 2015
 17. PNPLA3 (Patatin-Like Phospholipase Domain
Containing 3)

• PNPLA3 gene (adiponutrin) encodes a transmembrane polypeptide chain exhibiting

triglyceride hydrolase activity which is highly expressed on the endoplasmic reticulum
and lipid membranes of hepatocytes and adipose tissue and in human stellate cells.
• Subpopulations of NAFLD patients with PNLA3 mutation are not associated with insulin
resistance, a hallmark of metabolic syndrome
• A distinct entity might exist in which the PNPLA3 risk allele appears to be a major driver
of disease progression in combination with viral infection, alcohol abuse, lifestyle
(unhealthy diet and inactivity), and/or non-lifestyle (cryptogenic) causes, Eg. PNPLA3-
associated steatohepatitis (“PASH”)
• M. Krawczyk, P. Portincasa, and F. Lammert, “PNPLA3-associated steatohepatitis: toward a gene-based
classification of fatty liver disease,” Seminars in Liver Disease, vol. 33, no. 4, pp. 369–379, 2013
 18. TM6SF2 (Transmembrane 6
Super family Member 2)

• TM6SF2 gene regulated hepatic triglyceride secretion and that the

functional impairment of TM6SF2 promoted NAFLD
• Carriers of the TM6SF2 E167K variant seem to be more at risk for
progressive NASH, but at the same time they could be protected
against cardiovascular diseases

• G. Musso, M. Cassader, E. Paschetta, and R. Gambino, “TM6SF2 may drive postprandial lipoprotein cholesterol
toxicity away from the vessel walls to the liver in NAFLD,” Journal of Hepatology, vol. 64, no. 4, pp. 979–981, 2016.
 FFAs
HSL
B-oxidation
TG
TG
TG Peroxisome

TG TG

FFAs Cholesterol
TG Phospholipids VLDL

Chylomicrons TGs in lipid

dropletes

DNL
Glucose +
Fructose HSL : Hormone sensitive lipase
DNL : de novo lipogenesis
FFAs: Free fatty acids
VLDL : Very low density lipoproteins
 Insulin FFAs
HSL 1) Insulin Resistance
B-oxidation
TG
TG
TG Peroxisome
TG TG
FFAs cause
defective FFAs Cholesterol
TG insulin Phospholipids VLDL
signaling

Chylomicrons Lipid droplets in

hepatocytes

DNL
SREBP-1 SREBP-1 : sterol regulatory element-binding protein 1
IRS-2 : insulin receptor substrate 2
FFAs: Free fatty acids
VLDL : Very low density lipoproteins
IRS-2
METABOLISMCLINICALANDEXPERIMENTAL65(2016)1038–1048
 Insulin FFAs
HSL ROS INFLAMMATION 1) Insulin Resistance
FIBROSIS
TG
B-oxidation APOPTOSIS 2) Mitochondrial
TG Dysfunction
TG Peroxisome
TG TG
FFAs cause
defective FFAs Cholesterol
TG insulin Phospholipids VLDL
signaling Stellate cells

Chylomicrons Lipid droplets in

hepatocytes

ROS : Reactive oxygen species

DNL TG : Triglycerides
FFAs : Free fatty acids
SREBP-1 SREBP-1 : sterol regulatory element-binding protein 1
IRS-2 : insulin receptor substrate 2

IRS-2 Ferramosca A et al . Antioxidants and fatty liver

METABOLISMCLINICALANDEXPERIMENTAL65(2016)1038–1048
 Insulin FFAs 1) Insulin Resistance
HSL ROS INFLAMMATION
FIBROSIS
TG
B-oxidation APOPTOSIS 2) Mitochondrial
TG Dysfunction
TG Peroxisome
TG
3) ER Stress
TG
FFAs cause
defective FFAs Cholesterol
TG insulin Phospholipids VLDL
Stellate cells
signaling

Chylomicrons Lipid droplets in ER

hepatocytes • Dec protein
UPR synthesis
DNL • Incr Protein
transit and
degredation
SREBP-1 JNK INFLAMMATION
APOPTOSIS
JNK : c-jun terminal kinase Impaired insulin signaling
IRS-2 UPR : unfolded protein response
IRS-2 : insulin receptor substrate 2
METABOLISMCLINICALANDEXPERIMENTAL65(2016)1038–1048
 Insulin FFAs
ROS INFLAMMATION
1) Insulin Resistance
HSL
B-oxidation
FIBROSIS
APOPTOSIS
2) Mitochondrial
TG
TG Dysfunction
TG Peroxisome 3) ER Stress
TG FFAs cause
TG
defective 4) Adipose tissue
insulin Cholesterol
TG signaling
FFAs
Phospholipids VLDL
Dysfunction
Stellate cells
Leptin
TNF-α
IL-6

Chylomicrons Lipid droplets in ER

hepatocytes • Dec protein
UPR synthesis
DNL • Incr Protein
transit and
degradation
SREBP-1 JNK INFLAMMATION
APOPTOSIS
Impaired insulin signaling
IRS-2 Ferramosca A et al . Antioxidants and fatty liver
METABOLISMCLINICALANDEXPERIMENTAL65(2016)1038–1048
 Insulin FFAs
ROS
INFLAMMATION 1) Insulin Resistance
HSL FIBROSIS
B-oxidation APOPTOSIS
2) Mitochondrial
TG
TG Dysfunction
TG Peroxisome 3) ER Stress
TG FFAs cause
TG
defective 4) Adipose tissue
insulin Cholesterol
TG signaling
FFAs
Phospholipids VLDL
Dysfunction
Stellate cells
Leptin 5) Dysbiosis
TNF-α
IL-6

Chylomicrons Lipid droplets in ER

hepatocytes • Dec protein
UPR synthesis
DNL • Incr Protein
transit and
LPS degradation
SREBP-1 JNK INFLAMMATION
APOPTOSIS
Impaired insulin signaling
IRS-2 LPS: Lipopolysaccharide
METABOLISMCLINICALANDEXPERIMENTAL65(2016)1038–1048
 Insulin FFAs
ROS
INFLAMMATION 1) Insulin Resistance
HSL FIBROSIS
B-oxidation APOPTOSIS
2) Mitochondrial
TG
TG Dysfunction
TG Peroxisome 3) ER Stress
TG FFAs cause
TG
defective 4) Adipose tissue
insulin Cholesterol
TG signaling
FFAs
Phospholipids VLDL
Dysfunction
Stellate cells
Leptin 5) Dysbiosis
TNF-α
IL-6 6) Inflammatory
Lipid droplets in ER State
Chylomicrons
hepatocytes • Dec protein
UPR synthesis
DNL • Incr Protein
transit and
LPS degradation
SREBP-1 JNK INFLAMMATION
APOPTOSIS
NF-kB Impaired insulin signaling
IRS-2 NF-kB : Nuclear factor-jB kinase-b
METABOLISMCLINICALANDEXPERIMENTAL65(2016)1038–1048
 Insulin FFAs
ROS
INFLAMMATION 1) Insulin Resistance
HSL FIBROSIS
B-oxidation APOPTOSIS
2) Mitochondrial
TG
TG Dysfunction
TG Peroxisome 3) ER Stress
TG FFAs cause
TG
defective 4) Adipose tissue
insulin Cholesterol
TG signaling
FFAs
Phospholipids VLDL
Dysfunction
Stellate cells
Leptin 5) Dysbiosis
TNF-α
IL-6 6) Inflammatory
Lipid droplets in ER State
Chylomicrons
hepatocytes • Dec protein
UPR synthesis
DNL • Incr Protein
transit and
LPS degredation
SREBP-1 JNK INFLAMMATION
APOPTOSIS
NF-kB Impaired insulin signaling
IRS-2
METABOLISMCLINICALANDEXPERIMENTAL65(2016)1038–1048
Histology of NASH
 Extra Hepatic Complications of NAFLD

• 90% of NAFLD patients have at least one feature of the metabolic

syndrome and up to 33% meet the complete diagnosis - metabolic
syndrome
• Cardiovascular Disease
• NAFLD is an independent risk factor for coronary artery disease, as
well as being strongly associated with a number of other
cardiovascular risk factors, including multi-organ insulin resistance,
dyslipidaemia and impaired flow-mediated vasodilatation
• Insulin Resistance and Type II Diabetes Mellitus
• Insulin Resistance (IR) is the most common metabolic abnormality
associated with NAFLD
 Diagnostic Tools
Maintenance of high index of suspicion

• Transaminases
1 Clinical Features 2 Serum Biomarkers 3 Imaging Techniques 4 Liver Biopsy
ALT. AST
• Total Bilirubin
• Proinflammatory • Abdominal
• Over weight / • Infammation
markers ultrasound
Obesity • Fibrosis
• Cytokines • Magnetic
• Hypertension (CV • Cellunalr
• Hepatocyte resonance
Disease) infiltration
apoptosis Imaging
• Insulin Resistance
markers • Transient
(Type II DM)
• Lipid profile (TG, Elastography
• > 3 years old
FFA, Cholesterol)
• Family h/o.
• Serum
NAFLD
autoantibodies
• Hepatomegaly
• Acanthosis
nigricans
 Diagnosis of NAFLD?

• In 10% of NASH patients, ALT and AST may be normal,

especially with simple steatosis.
• AST/ALT ratio < 1—this ratio is usually > 2 in alcoholic
hepatitis.
• An abnormal ferritin level in the presence of normal
transferrin saturation should always suggest a need to rule
out NASH.
U/S Appearance - (NAFLD)

• Hepatic steatosis
• No inflammation
• Can be diagnosed with
imaging alone
• Low risk for disease
progression
 Radiology - NAFLD?

• Increased echogenicity • Low attenuation compared

• Hepatomegaly with the spleen
 Histopathology - NASH?
• Liver biopsy is the GOLD standard

Do we have to do a biopsy on
EVERYONE with fatty liver
disease??
 Non-invasive Diagnose of NASH??

• Vibration Controlled Transient

Elastography (Fibroscan) : uses sound
waves to measure the stiffness of liver
tissue.
• MRI Elastography (MRE): to capture
images of shearwave propagation in the
liver producing an elastogram that maps
liver stiffness values with high resolution
• Multiparametric MRI (Liver Multiscan)
• Circulating levels of cytokeratin-18
(CK18)
 Differential Diagnosis

• Alternate causes of fatty liver:

• Alcohol
• Wilson’s Disease
• Hepatitis C (genotype 3)
• Starvation
• TPN
• Medications (EX: methotrexate, tamoxifen,
corticosteroids)
 Management of paediatric NAFLD
1st Lifestyle Intervention 2nd Pharmacotherapy 3rd Bariartic Surgery
Diet and Physical exercise
(Education + Intervention) Insulin sensitisers
• Decrease caloric intake • Metformin • Gastric banding
• Decrease fat intake • Incretin mimetics
• Decrease fructose • DDP-4 inhibitors • Gastric bypass
intake • Thiazolidinediones
• Decrease alcohol intake Weight loss: • Sleeve
• Increase physical • Orlistat
exercise Cholesterol regulation: gastrectomy
Supplementations: • Statins
• Vitamin D Antiocidants • Intragastric
• Omega-3 fatty acids • Ursodeoxycholic acid
• Vitamin E balloon
Probiotics

Am J Gastroenterol 2012; 107:811–826

Management of paediatric NAFLD

CAUSE TREATMENT
Obesity Diet, exercise
Nutritional Increase vitamins/fiber
deficiencies
Insulin resistance Metformin, pioglitazone
Oxidative stress Antioxidants
Cytokines, Anticytokine therapy
adipokines
Bacterial Probiotics/antibiotics
overgrowth
Hyperlipidemia Antihyperlipidemics

Adapted from NEJM 2006;355(22):2361.

 1) Review of clinical history
2) RUQ US
3) Full liver enzymes evaluation (rule out viral hepatitis,
autoimmune disease, hemochromatosis, etc

US(+), no clear alternate

US(-) etiologies

The Lowly fellow’s Continue LFT 1) Imaging assessment of Fibrosis (Fibroscan

evaluation as or MRE)
algorithm for necessary 2) Review clinical risk
elevated LFTS and/or
Continue liver enzyme Elevated Liver stiffness
concern for NAFLD: evaluation as necessary Normal liver stiffness Clinically increased risk
No liver
Liver biopsy
Biopsy
for staging
Encourage lifestyle modifications
?Vitamin E
Weight loss accountability Non NASH
NASH
Continue to reassess need for staging NAFLD
(if not already done)
 Summary

• What is NAFLD?
• Fat in the liver +/- inflammation and/or fibrosis
• How does NAFLD occur?
• Excess fat, insulin resistance, oxidative damage
• How big of a problem is this?
• HUGE!! 2nd leading cause of liver transplant in the U.S. and climbing.
• What populations are at higher risk?
• Those with obesity, diabetes, HLD, HTN, and of Hispanic heritage
• How can I diagnose NAFLD?
• Imaging. Diagnosing with NASH takes specialized tests.
• How do I manage my patients with NAFLD?
• Lifestyle modifications!! Weight loss is key.
• Dr CSN Vittal